Inspection Reports for TerraBella Hendersonville

This is a Construction Section Biennial Follow Up Survey conducted to verify correction of previously identified deficiencies related to sanitation, fire safety, and physical plant conditions.

Deficiencies remain uncorrected including lack of current fire and building safety inspection reports, unsafe outside premises with trip hazards, and failure to maintain fire safety equipment such as the sprinkler system and emergency fire alarm system in operating condition.

The Adult Care Licensure Section conducted an annual survey of the facility from April 9 to April 10, 2025.

The facility failed to provide personal care assistance with showers for one of six sampled residents who required assistance, specifically Resident #8, who did not receive the scheduled twice-weekly showers as required by her care plan.

The report documents a Construction Section Biennial Survey conducted to assess compliance with licensure, building codes, and physical plant requirements for an adult care home.

Multiple deficiencies were cited including failure to meet physical plant requirements, lack of current fire and building safety inspection reports, obstructions in corridors, unclean and unsafe outside premises, chronic unpleasant odors, failure to conduct fire safety rehearsals on each shift, and multiple fire safety equipment and building maintenance issues such as non-operational sprinkler and fire alarm systems, unsealed penetrations in fire-rated ceilings, malfunctioning doors, electrical hazards, plumbing issues, and non-functioning exhaust ventilation.

The Adult Care Licensure Section completed a follow-up survey on 03/20/24-03/22/24 and 03/25/24 to assess compliance with previously identified deficiencies.

The facility failed to provide adequate supervision for two residents with a history of multiple falls, failed to ensure residents' rights were maintained including timely response to call bells, failed to discontinue a medication as ordered increasing risk of harm, allowed unqualified staff to administer medications, and failed to report an injury of unknown origin to the Health Care Personnel Registry within 24 hours.

The Adult Care Licensure Section and the Henderson County Department of Social Services conducted a follow-up and complaint survey on 10/31/23 - 11/01/23 regarding concerns about the facility's response to a resident's fall and missing status.

The facility failed to immediately respond when Resident #4 was not located around 12:15pm with her bathroom door locked and no response to calls. Approximately 6 hours later, staff were alerted by the resident's family that she had fallen and required help. Resident #4, who was on blood thinners, sustained a facial hematoma requiring hospitalization for 6 days. This failure constituted serious physical harm and neglect.

The visit was complaint-related and substantiated, as the facility failed to respond promptly to Resident #4 being missing and locked in the bathroom, leading to serious physical harm.

The Adult Care Licensure Section conducted an annual and follow-up survey from 08/29/23 to 08/31/23 with a desk review and exit conference on 09/01/23.

The facility failed to ensure physician-signed care plans within 15 days for sampled residents, failed to provide adequate supervision for a resident with wandering and multiple falls, failed to assist residents with dignity during meals, failed to clarify medication orders leading to duplicate vitamin D3 administration, failed to administer Lasix as ordered, and failed to obtain required Special Care Unit disclosure statements for residents.

The Adult Care Licensure Section conducted an annual and follow-up survey on 01/11/22 and 01/12/22 to assess compliance with medication administration and infection prevention and control requirements.

The facility failed to administer medications as ordered for one resident due to a delay in medication refill, resulting in a 4% medication error rate during the observed medication pass. Additionally, the facility failed to ensure appropriate COVID-19 screening of residents, including daily temperature checks and symptom screening, despite being in outbreak status.

Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies.

Several deficiencies related to physical plant and safety were observed, including staff unawareness of emergency release switch, improperly positioned cooking equipment, compromised fire-rated walls and ceilings, and an unsupervised range in the memory care activity room. Some deficiencies were corrected during the survey, but further action is required.

The report documents a Construction Section Biennial Survey conducted on 2019-06-05 to assess compliance with physical plant, fire safety, and other regulatory requirements for Carillon Assisted Living of Hendersonville.

Multiple deficiencies were identified including lack of staff awareness of emergency release switches, missing hand grips in bathrooms, unsafe storage and handling of medical oxygen cylinders, improper use of extension cords, fire safety plan and rehearsal deficiencies, sprinkler system malfunctions, compromised fire-rated walls and doors, excessive combustible storage, missing monthly inspection documentation for fire suppression and extinguishers, hot water temperatures exceeding safe limits, and non-functioning exhaust ventilation.

The Adult Care Licensure Section and the Henderson County Department of Social Services conducted an annual survey on 07/31/18 and 08/01/18 at Carillon Assisted Living of Hendersonville.

The facility failed to complete required medical examination forms within 72 hours of admission for one resident and failed to provide adequate personal care assistance, including showers, bed making, and linen changes, to three of eight sampled residents. Staff shortages and prioritization issues contributed to residents not receiving scheduled personal care services.

Biennial construction section survey conducted to assess compliance with licensing and building codes for Carillon Assisted Living of Hendersonville.

Multiple deficiencies were cited including failure to maintain current sanitation and fire safety inspection reports, inadequate fire safety rehearsals on each shift, emergency equipment not maintained in safe operating condition, doors not properly latching to contain smoke, and insufficient exhaust ventilation in the women's restroom.

The Adult Care Licensure Section and the Henderson County Department of Social Services conducted an annual survey on April 14-15, 2015 to assess compliance with state regulations.

The facility failed to maintain hot water temperatures within the required range of 100 to 116 degrees Fahrenheit at multiple fixtures in both the assisted living and Special Care Unit (SCU). Observations revealed several fixtures with temperatures exceeding 116 degrees F. Interviews and record reviews indicated inconsistent water temperature monitoring and possible 'hot pockets' in the circulating system. The facility had no reported injuries or complaints related to the issue and had a plan of correction in place.

Biennial Construction Survey conducted to assess compliance with building and fire safety codes applicable to adult care homes.

The survey found multiple deficiencies including compromised one-hour fire rated walls and ceilings, cross-corridor doors not latching properly, non-functional emergency lighting, and unsafe storage of medical oxygen cylinders.